The Centers for Disease Control and Prevention has released sexually transmitted disease surveillance data for 2012, and the news is not good: Cases of chlamydia, gonorrhea, and syphilis all continued to rise.

Last Wednesday, the Centers for Disease Control and Prevention (CDC) released sexually transmitted disease (STD) surveillance data for 2012, and the news is not good. Cases of chlamydia, gonorrhea, and syphilis—the three disease that must be reported to the CDC—all continued to rise. In fact, there were over 1.4 million cases of chlamydia reported to the CDC in 2012, the most ever. There were also 334,826 cases of gonorrhea and 15,667 cases of primary and secondary syphilis.

When looking at the rates, syphilis is the most alarming, as there were five cases per 100,000 individuals, which represents an 11 percent increase over the previous year. Gonorrhea rates increased 4 percent from the year before, to 107 cases per 100,000 individuals.

Rates for chlamydia were more stable, increasing only 0.7 percent since 2011. Still, there were 456 cases per 100,000 individuals.

To understand the scope of this epidemic, however, we have to remember that this data represents reported cases, but many cases of these STDs go undiagnosed and unreported. We also have to remember that other common STDs, such as trichomoniasis or human papillomavirus (HPV), are not reportable and, therefore, not included in the new data.

The data also makes it clear that some populations—specifically, men who have sex with men (MSM) and young people—are significantly more affected than others. For example, the CDC notes that men who have sex with men account for 75 percent of all primary and secondary syphilis cases. Though syphilis can be treated, if not caught it can lead to serious health conditions such as blindness or stroke. Moreover, infection with syphilis increases the risk of individuals both acquiring and transmitting HIV. In fact, data suggests that as many as 40 percent of MSM with syphilis are also infected with HIV.

More than half of all cases of both chlamydia and gonorrhea are seen in young people between the ages of 15 and 24. The CDC reports that 24 percent of chlamydia cases occur in young people ages 15 to 19, and 34 percent in those ages 20 to 24. Similarly, 30 percent of gonorrhea cases occur in young people ages 15 to 19, and 39 percent in 20- to 24-year-olds. These are both curable STDs; however, if left untreated they can cause long-term health problems. In particular, the CDC estimates that undiagnosed STDs cause 24,000 women to become infertile each year. In addition, as RH Reality Checkhas been reporting over the last few years, gonorrhea has become resistant to many antibiotics used to treat it in the past, and there are now only a few drugs that work to cure some strains of this bacteria. Public health experts are concerned that without the introduction of new antibiotics, gonorrhea may become difficult, if not impossible, to cure in the future.

“The ever-increasing rates of sexually transmitted diseases continue to threaten the health and well-being of millions of Americans, particularly youth and men who have sex with men,” said William Smith, executive director of the National Coalition of STD Directors, in a statement. “The long-term consequences of these diseases impact the health of the individual, burden our larger health care system, and drastically hinder our continued fight against HIV and AIDS.”

“Simply put, STD public health programs do not have enough resources to address all the serious problems that face them. As a result, thousands, if not millions, of Americans at risk for STDs are not able to be reached, which has long-term human and economic costs,” said Smith. “STD programs desperately need additional funding to address these rising rates and meet our STD epidemics effectively.”

In addition to increasing the resources available to STD programs, there are steps that should be encouragedat the individual level to thwart the epidemic. First and foremost, sexually active individuals need to be reminded of the risks of STDs as well as measures they can take to reduce risk—most importantly, condom use. Research has shown that condoms are highly effective at preventing all three of the STDs included in this data.

Regular screenings also can help keep individuals from unknowingly passing the infection on to others, while preventing their own long-term conditions. The CDC recommends that all women age 25 and under get screened for chlamydia annually, and that MSM and women with risk factors, such as a new partner or multiple partners, be screened for chlamydia, gonorrhea, syphilis, hepatitis B, and HIV each year. MSM who have multiple or anonymous partners should be screened at three- to six-month intervals.

The CDC surveillance numbers for 2011 show that gonorrhea and chlamydia are up especially among young people and that three-quarters of all syphilis cases are among men who have sex with men; an analysis of STIs in New York City finds they are inextricably linked to poverty, and research suggests dormant HPV may reactivate as women near menopause.

CDC Releases STI Statistics for 2011, Rates Go Up Especially Among Young People and MSM

Last week the Centers for Disease Control and Prevention (CDC) released tracking data on three Sexually Transmitted Infections (STIs): Chlamydia, Gonorrhea, and Syphilis. The news is not great; rates of these infections are going up especially among some groups.

1.4 million chlamydia infections were reported to the CDC. The rate of cases per 100,000 people increased 8 percent, to 457.6 in 2011 from 423.6 in 2010.

321,849 gonorrhea infections were reported to the CDC. The rate increased 4 percent to 104.2 cases per 100,000 in 2011 from 100.2 in 2010.

13,970 cases of primary and secondary syphilis were reported to the CDC. The rate of 4.5 cases per 100,000 was unchanged from 2010.

According to the report, the majority of cases of both gonorrhea and chlamydia were found in young people ages 15 to 24. Specifically, 27 percent of gonorrhea cases were among adolescents ages 15 to 19 and 35 percent of gonorrhea cases were among young adults ages 20 to 24. The break downs for chlamydia cases were similar with adolescents 15 to 19 accounting for 32 percent of the cases and young adults ages 20 to 24 accounting for 38 percent of cases. This is particularly disturbing because if untreated both chlamydia and gonorrhea can lead to Pelvic Inflammatory Disease which is a major cause of infertility among young women.

The 2011 trends for syphilis found that 72 percent of cases of primary and secondary syphilis occurred among men who have sex with men. The CDC explains that primary and secondary syphilis “are the most infectious stages of the disease, and if not adequately treated, can lead to visual impairment, stroke, and in rare cases, even death.” Syphilis also increases an individual’s risk for HIV infection—in part because it increases an HIV-positive individual’s viral load which makes him/her more contagious. The CDC concludes:

“Given the high prevalence of HIV in the MSM community, increasing syphilis infections among men who have sex with men are particularly troubling.”

This report is a good opportunity to look at trends in reported cases of STIs but it likely does not capture the extent of this epidemic of this country. In truth, these STIs often have no symptoms and many individuals who are infected go undiagnosed. Moreover, the CDC does not collect data on other common STIs including HPV, Herpes, and trichomoniasis, all of which are quite widespread. In total, the CDC estimates that over 19 million new cases of STIs occur in this country each year and that STIs cost the health care system approximately 17 billion dollars each year.

To combat this epidemic the CDC recommends that all sexually active young women under 25 and all older women considered at-risk (such as those in new relationships or communities with high STI rates) get screened for Chlamydia each year; at-risk sexually active women should be screened for gonorrhea annually; and all sexually active men who have sex with men should be screened each year for chlamydia, gonorrhea, syphilis, and HIV.

It is also important to remember that condoms are highly effective in preventing STDs.

STIs in New York City Concentrated in a Few Zip Codes

Also released last week was a report by New York City’s Department of Health and Mental Hygiene that used 2010 STI data and census data to determine where the city’s STI cases were most concentrated. The department analyzed disease data on HIV/AIDS, hepatitis B, hepatits C, chlamydia, gonorrhea, syphilis, and tuberculosis (which is a communicable disease though not sexually transmitted). High-morbidity zip codes were defined as those with disease rates in the top 20 percent of all NYC zip codes. Zip codes were then given a score (0-7) indicating the number of diseases for which they had rates in the top 20 percent.

The study found that: 68 percent of zip codes in the Bronx were in the top 20 percent for multiple STDs, compared to 45 percent of zip codes in Manhattan, 25 percent in Queens, and 22 percent in Brooklyn. No zip codes in Staten Island were in the top fifth for multiple STDs.

Not surprisingly, poverty and STI Rates are inextricable linked. The study found that 19 zip codes with high rates of poverty in the South Bronx, north-central Brooklyn, and northern Manhattan had HIV/AIDS, chlamydia, and gonorrhea rates in the top 20 percent. Perhaps most telling are the results for the Tremont section of the Bronx. This neighborhood ranked in the top quintile for all of the seven diseases surveyed and 43 percent of its residents live below the federal poverty line.

HPV Makes a Comeback in Menopausal Women

A new study in the Journal of Infectious Diseases suggests that HPV may make a comeback in women as they near menopause. The study looked at over 850 women ages 35 through 60 who had cervical cancer screening between 2008 and 2011. Though the study did find that women who had had a new sexual partner within the six months prior to screening were more likely to have HPV, these women accounted for only 3 percent of those in the sample. Other women tested positive for HPV without having had new partners. Researchers believe the cause of this to be a reawakening of a dormant infection.

The researchers suggest that a woman’s immune system may be capable of controlling or suppressing HPV when she is young but as the immune system weakens with age, the virus can come back. They liken this to what has been show to happen with the varicella zoster virus which causes chicken pox: “The virus can lie dormant in the bodies of people who were infected as children, then come raging back as shingles later in life.” Though linked primarily to cervical cancer, HPV is also linked to cancers of the head and neck, vulva, vagina, penis, and anus all of which could pose great risk for the older population.

This new research also found that the 77 percent of the women who tested positive for HPV reported having had five or more lifetime partners. The researchers suggest that the women entering menopause now—who came of age during or after the sexual revolution of the 60’s and 70’s—will be at far greater risk of reactivated HPV infections than the generations before them who were much less likely to be exposed to the virus in the first place.

The authors conclude that these finding may mean we have to change our screening measures to include more regular pap smears for women over 40 years of age.

]]>http://rhrealitycheck.org/article/2012/12/18/sti-news-chlamydia-and-gonorrhea-rates-rise-stis-in-nyc-concentrated-in-low-incom/feed/0MSM, STDs and HIV: What Are We Missing?http://rhrealitycheck.org/article/2011/04/27/stds-what-missing/?utm_source=rss&utm_medium=rss&utm_campaign=stds-what-missing
http://rhrealitycheck.org/article/2011/04/27/stds-what-missing/#commentsWed, 27 Apr 2011 11:18:12 +0000Across the United States and worldwide, MSM continue to be a group disproportionately affected by STDs and HIV, but we still need better data and better tools to guide prevention efforts.

April is STD Awareness month. This article is one in a series published by RH Reality Check in partnership with the National Coalition of STD Directors, focused on aspects of STD prevention, treatment and funding and the public health implications of neglecting STDs.

I often reflect on how much goes on in the STD world that needs to be hollered from the proverbial rooftops. Recently, my friend and NCSD Board Member, Susan Philip, who directs the STD program in San Francisco, has been helping me understand the import of having more frank and open conversations about the unique challenges that men who have sex with men (MSM) face in protecting their sexual health.

Across the United States and worldwide, MSM continue to be a group disproportionately affected by STDs and HIV, but we still need better data and better tools to guide prevention efforts. This is particularly true for STDs.

For example, we have had a large national emphasis on syphilis elimination since 1999 and have more recently worked to address both issues of co-infection in HIV-infected persons and also the increased risk of HIV infection in HIV-uninfected patients with syphilis.

And while much deserved attention is paid to syphilis in this regard, we should not forget that chlamydia and gonorrhea are much more common STDs, although we are less able to measure their impact on the health of MSM. Patients who are diagnosed with infectious syphilis are typically interviewed by local or state health department staff (individuals are always given the option to decline answering some or all of these questions), and this information includes the numbers and gender of partners they have had, where they met them and the types of sex they had with partners. This information helps local STD programs, as well as the CDC and other partners in sexual health, better understand who is at risk for syphilis, and most importantly, direct prevention resources more effectively.

However, obtaining these data are possible because there are specific federal funds to support syphilis control and prevention efforts, and because even in areas with high syphilis morbidity, the case counts are much lower than for gonorrhea or chlamydia. Yet, in many other places across the country, it is often not feasible to interview all of the individuals diagnosed with gonorrhea and chlamydia. Because we lack this type of interview information about partners, we don’t reliably know which individuals with gonorrhea and chlamydia are MSM, and therefore cannot assess the impact of these STDs on health. Recognizing that we cannot begin to address sexual health disparities in MSM without good data, several states and cities including California are changing reporting requirements to include gender of sex partners when providers or laboratories report new cases of STDs to health officials.

In areas where gender of sex partners is collected routinely, STD disparities are commonly found. In San Francisco in 2010, an estimated 1 in 100 MSM was infected with early syphilis, but diagnoses of chlamydia or gonorrhea were twice as common as syphilis. Furthermore, gonorrhea rates were 18 times higher in MSM than in heterosexual men. For chlamydia, they were 8 times higher.

However, we won’t be able to diagnose and treat these infections unless there are comprehensive sexual health services available to MSM. This requires obtaining an accurate sexual history and providing the best type of tests – for not only urine, but also the throat and rectum if individuals have receptive oral and anal sex. These areas have been shown to be common sites of gonorrhea or chlamydia infection. In addition, the majority of infections are asymptomatic, and more than half of all infections are missed if only urine testing is done. In other words – a whole bunch of folks think they are STD-free when given their results from a urine screening, when in fact, they have active infections in these other sites.

Why is this important? Certainly these STDs should be identified and treated to prevent complications in the infected individual, transmission to partners, and from potentially entering into larger sexual networks (a major issue in some urban areas and among those seeking sex in on-line sex seeking venues). In addition, we must continue to educate even ourselves that observational data have shown that STDs are associated with increased risk of acquiring HIV.

For example, in data published in the Journal of AIDS in 2010, Kyle Bernstein and colleagues in San Francisco were able to show that for HIV-uninfected men at City Clinic, the municipal STD clinic in San Francisco, having a rectal chlamydia or gonorrhea infection was associated with a two times greater risk of becoming newly HIV-infected in the following two years. Strikingly, the risk was further increased in those with two rectal infections, and was higher still in those diagnosed with rectal chlamydia or gonorrhea three times during the study period. From these data, we cannot distinguish whether the rectal STDs are causing an increased risk of new HIV infections or are just associated with a new HIV diagnosis. But, does it really matter? These data suggest that by identifying HIV-uninfected MSM with rectal infections, we are identifying a group that is at very high risk for HIV infection and could potentially benefit from focused prevention resources – this of course begins with STD treatment and regularized screening of all potential infections sites, but extends as well to behavioral interventions such as risk reduction counseling, motivational interviewing, and skills building and other biomedical interventions, such as HIV pre-exposure prophylaxis.

Given the challenges of improving sexual heath for all Americans, we must do a better job of both documenting the disparities that MSM face in sexual health, as well as employing all available prevention tools in our efforts to address them.

]]>http://rhrealitycheck.org/article/2011/04/27/stds-what-missing/feed/1The Persistence of Syphilis and Issues of Health Equity in Americahttp://rhrealitycheck.org/article/2011/04/25/persistence-syphilis-issues-health-equity-america/?utm_source=rss&utm_medium=rss&utm_campaign=persistence-syphilis-issues-health-equity-america
http://rhrealitycheck.org/article/2011/04/25/persistence-syphilis-issues-health-equity-america/#commentsMon, 25 Apr 2011 21:55:30 +0000On the horizon is a greater integration of services and population level outcomes with health rather than individual disease case numbers as the sole measure of success or failure. And syphilis reminds us of why this is so utterly necessary.

April is STD Awareness month. This article is one in a series published by RH Reality Check in partnership with the National Coalition of STD Directors, focused on aspects of STD prevention, treatment and funding and the public health implications of neglecting STDs.

Syphilis elimination, a term that may now seem inappropriate for a period of fiscal constraint, was launched in October of 1999 at a time when syphilis rates were low and over half of all incident cases where located in 28 counties nationally. In concept, it served a purpose in galvanizing attention to the inequities surrounding syphilis rates in the United States. Jeffrey Kaplan, the then-director for the CDC said so himself:

“This disease, like others, serves as a sentinel for broader health and societal problems that we need to address. People who live in poverty, lack employment, and who lack access to quality health care are vulnerable to this and other diseases. So, as we target our efforts and work at strengthening and involving the state and local health departments, community groups, and communities of faith, we should see a difference not just in syphilis rates, but in a range of other health conditions that go hand in hand with it.” [1]

The disparities of this historically endemic disease were and still are tied to poverty, the lack of guaranteed access to medical care, the continued stain of racism, and the contextual factors that contribute to the many non-sexual health inequities we see in our society.[2] Still, throughout much of the Southern United States, the Syphilis Elimination Effort brought the rates for heterosexually-transmitted disease to new historic lows — only to now see overall disease rates rise again across the US and with a newer, more narrowed population.

The current epidemic is a different one, but one that still most adversely affects those so often marginalized in our society. This twenty first century epidemic shifted from one of primarily heterosexual transmission to one that affects men who have sex with men (MSM) in ever-higher numbers. While heterosexual transmission reached historic lows, congenital syphilis increased by 23 percent from 2005 to 2008. Most of this increase occurred among infants born to black mothers in the South. Syphilis elimination had a setback in the two outcomes that mattered most, HIV and congenital syphilis.

From the start, we knew an approach that was primarily “medical” could never eliminate a pathogen whose existence is so tied to societal inequities. We knew it then, but we lacked the political will to address the underlying factors that contributed to the persistence of this centuries old scourge. We may hold out that health care reform might indeed lift all boats, but even the politicization of that effort underscores the sad news that this courage is still profoundly wanting and when demonstrated, splits our nation in two. All the while, syphilis continues its ravenous onslaught.

To complicate matters further, the current economic crisis has led to a cutting of funding resources to STD control programs and a closing of many categorical STD clinics. The situation is not pretty, but as we seek to address the drivers of health inequity in our society, we must nonetheless reconsider our approach to syphilis going forward if indeed we hope to again bring rates down. And I would argue, tackling two facets of the current epidemic drive at the very heart of the health inequity issue and can, as Jeffrey Kaplan reminds us, help us on both fronts.

First, a concerted, robust, and honest focus on both men who have sex with men (MSM) and HIV infected individuals must be prioritized. The synergy of syphilis and HIV has been well described and should be a priority for everyone working to promote sexual health among MSM and those living with HIV. Syphilis and HIV are engaged in a bizarre dance with one another, and it is playing itself out among these two populations. For example, the recent increases of syphilis in young MSM of color preceded the increase in both the incidence and prevalence of HIV in this population.[3][4] In North Carolina, co-infection of HIV in men with incident syphilis went from 5 percent in the late nineties to nearly 50 percent in 2009. These realities require a greater integration of screening for HIV and syphilis in clinical settings such as STD clinics, non-traditional HIV test sites targeting MSM, and HIV clinics. These actions cut to the core of efficiency and effectiveness in a budget constrained environment.

And at the same time, the societal factors that drive this situation among MSM and those with HIV can serve as additional longer-term aspirations to ensure greater sexual health.

Second, congenital syphilis – mother-to-child transmission of syphilis – reflects a profound breach in our health care system and not a mere failure of screening programs. All states require syphilis screening of pregnant women with a resulting near universal screening of women who are engaged in prenatal care. And while congenital syphilis is an entirely preventable disease, it persists in the US and is almost exclusively limited to women outside of prenatal care. In essence, the persistence of congenital syphilis continues to underscore that too many pregnant women are not linked to and retained in early prenatal care. Yet, the benefits of universal enrollment in prenatal care, and efforts to ensure retention, far overshadow the cost and health outcomes in just “preventing” congenital syphilis. Collaboration between maternal/child health and STD programs is essential but not sufficient to eliminate congenital syphilis in the US. The recent increase in congenital syphilis cases demonstrate the danger of even low level syphilis transmission in populations where sex is linked to economic survival and to the use of crack cocaine.

The emerging domestic notion of a “sexual health” agenda, with accompanying attention to the types of health services that ensure it, compels us to move away from siloed programmed thinking. On the horizon is a greater integration of services and population level outcomes with health rather than individual disease case numbers as the sole measure of success or failure. And syphilis reminds us of why this is so utterly necessary.

So as we move beyond a singularly medical model for syphilis control, it is accompanied by a commitment that syphilis is not possible through test and treat if the conditions that allow its persistence are not addressed too. A focused effort to reduce the impact of syphilis on HIV transmission and congenital syphilis is possible while we continue to understand and commit as a society to reducing health and social inequities.

]]>http://rhrealitycheck.org/article/2011/04/25/persistence-syphilis-issues-health-equity-america/feed/0“Got STD Testing?:” Meeting the STD and HIV Testing Needs of Men Who Have Sex With Men (MSM)http://rhrealitycheck.org/article/2011/04/11/testing-meeting-testing-needs-have/?utm_source=rss&utm_medium=rss&utm_campaign=testing-meeting-testing-needs-have
http://rhrealitycheck.org/article/2011/04/11/testing-meeting-testing-needs-have/#commentsMon, 11 Apr 2011 08:23:44 +0000It’s rare that my MSM patients know which STDs they ought to be screened for, and how often. Men who have sex with men don’t get screened often enough for diseases like syphilis, gonorrhea, and HIV.

April is STD Awareness month. This article is one in a series published by RH Reality Check in partnership with the National Coalition of STD Directors, focused on aspects of STD prevention, treatment and funding and the public health implications of neglecting STDs.

Got STD testing?

That’s right. Many people think about getting tested for Sexually Transmitted Diseases (STDs) like Madison Avenue made us think about buying milk: Just get it. When it comes to milk, that approach is fine. Milk is milk, regardless of who’s buying. Not so for STD testing. That’s because recommendations from the Centers for Disease Control and Prevention (CDC) regarding STD testing depend on the person getting tested, the gender of his or her sex partners, and the types of sex he or she is having with those partners. One size doesn’t fit all.

That distinction is critically important for men who have sex with men (MSM), among whom STDs (including HIV) exact a disproportionate toll and for whom CDC’s recommendations for STD screening are substantially different from its recommendations for women and men who have sex only with women. In my experience as a physician specializing in STDs, it’s rare that my MSM patients know which STDs they ought to be screened for, and how often. And studies show that MSM don’t get screened often enough for diseases like syphilis, gonorrhea, and HIV.

This lack of knowledge would be less of an issue if clinicians did a better job of safeguarding the sexual health of their MSM patients. But clinicians often don’t know the sexual orientation of their MSM patients – and even if they do, they often fall short of CDC recommendations in advising their MSM patients about their sexual health. The following recommendations are meant to help MSM patients get screened appropriately for STDs, including HIV:

First, know which tests you need, and how often.

Get the following STD tests every three to six months, if you’re sexually active, regardless of how often you use condoms during sex and even if you’re having no symptoms (since many STDs, including HIV, can cause no symptoms):

A test for HIV, if your last test was negative or you’ve never been tested.

A test of your urethra for gonorrhea and chlamydia, if you’ve had insertive anal sex or received oral sex in the past year (or since your last test). The urethra is the tube that takes urine through the penis. In the past, testing meant inserting a swab into the urethra. These days, fortunately, all it takes is a urine sample. The best tests for gonorrhea and chlamydia are called NAATs, pronounced like “gnats” and short for “nucleic acid amplification tests.” Ask for them.

A test of your rectum for gonorrhea and chlamydia, if you’ve had receptive anal sex in the past year (or since your last test). This is done with a (painless!) swab that’s inserted into your rectum. It should be tested with NAATs.

A test of your throat for gonorrhea, if you’ve given oral sex in the past year (or since your last test). This is also done with a swab. This can be a bit uncomfortable if you’ve got a strong gag reflex, since the swab hits the back of your throat. But it’s not too bad, and it only lasts a second or two. Then it’s tested with NAATs. (Note that CDC doesn’t specifically recommend chlamydia tests of the throat, but in practice most NAATs test for chlamydia and gonorrhea at the same time.)

You should also discuss with your doctor whether blood tests for hepatitis B, hepatitis C, and herpes simplex virus type 2 are right for you.

Second, know where to go.

Ask your doctor if he or she can do the tests above. If your doctor can’t, or if you don’t have a doctor, search for clinics that offer STD and HIV testing at findstdtest.org and hivtest.org, respectively. If you’re looking for a gay-friendly doctor, check out the Gay and Lesbian Medical Association’s directory.

Third, remember to get tested every 3–6 months.

Set reminders on your calendar. Or make a pact with a friend to get tested together at regular intervals, and remind each other. Or get reminded electronically. In San Diego County, where I work, we have a service, called “We All Test” (www.WeAllTest.com), that sends free email and/or a text message reminders to get tested for STDs every 3 or 6 months.

A handy sheet summarizing these tips is available for download here (although information on where to get tested is aimed at MSM in San Diego). Armed with this information, MSM asking the question “Got STD testing?” can make sure the answer they get is appropriate to keep them, and their partners, safe from STDs and HIV.

]]>http://rhrealitycheck.org/article/2011/04/11/testing-meeting-testing-needs-have/feed/2Smart Investments in AIDS and Global Health: Building on What Workshttp://rhrealitycheck.org/article/2009/12/01/smart-investments-aids-and-global-health-building-what-works/?utm_source=rss&utm_medium=rss&utm_campaign=smart-investments-aids-and-global-health-building-what-works
http://rhrealitycheck.org/article/2009/12/01/smart-investments-aids-and-global-health-building-what-works/#commentsTue, 01 Dec 2009 06:00:00 +0000The response to the
HIV/AIDS pandemic has transformed

This article is part of a series on global AIDS issues to be published
by RH Reality Check throughout December. It is drawn from a report
co-produced by amfAR (The Foundation for AIDS Research) and
The Center for Global Health Policy of the Infectious Diseases Society of America.

A full copy of the report including all tables,
graphs and references cited can be found here. Other articles in the series can be found by searching “global AIDS 2009″ on RH Reality Check.

The response to the HIV/AIDS pandemic has transformed global health financing and programming, demonstrating the potential to make substantial progress against diseases in low- and middle-income countries and placing a new emphasis on accountability, public engagement, and the health needs of the most vulnerable populations.

There are indications that the U.S. government is considering a significant slowing in the scale-up of global AIDS programming in 2010 and beyond. Such a slowdown would have serious negative impacts on both the global response to the AIDS epidemic and broader efforts to advance global health.

Instead of pulling back, U.S. policy makers should leverage the achievements of the AIDS response, continue the accelerated scale-up of HIV/AIDS prevention and treatment, and use these efforts as a foundation on which to build broader and more sustainable healthcare capacity in low- and middle-income countries. Such strategies capitalize fully on
global health investments made over the last several years.
Over the last decade the U.S. commitment to global HIV/AIDS initiatives has grown markedly.

The Response to the AIDS Pandemic to Date

Over the last decade the
U.S. commitment to global HIV/AIDS initiatives has grown
markedly.Funding for PEPFAR [The President’s Emergency Plan for AIDS Relief), which includes all bilateral funding for HIV and tuberculosis (TB), and U.S. contributions to the Global Fund to Fight AIDS, Tuberculosis and Malaria], has risen from $2.3 billion in FY 2004 to more than $6.6 billion in FY 2009. Among all sources worldwide, available funding to address the HIV/AIDS pandemic has grown from an estimated $2.1 billion in 2001 to $15.6 billion in 2008.

The Joint United Nations Programme on HIV/AIDS (UNAIDS) has documented many positive outcomes from these investments, including dramatically expanded coverage of lifesaving antiretroviral therapy (ART) among children and adults, from 5 percent of those in need in 2003 to 42 percent in 2008.

Many of the investments made in HIV/AIDS programs have also yielded important outcomes well beyond HIV and AIDS. There are preliminary but clear indications that investments in HIV/AIDS programs are demonstrating sustainable positive
results—establishing new healthcare infrastructure and
catalyzing policy change—that hold promise for improving healthcare for millions.
The HIV/AIDS response is beginning to reverse the overall trend in mortality

AstudyofUgandanadultsfounda95%reduction inmortalityin HIV-infected
individuals after 16 weeks of combination treatment with ART and co-trimoxazole, an 81% reduction in mortality in their
uninfected children younger than 10, and an estimated 93%
reduction in orphanhood.

In Brazil, ART has led to a 40–70 percent decrease in mortality, a 60–80 percent decrease in morbidity, an 85 percent decrease in hospitalization of people living with HIV/AIDS, and savings of $1.2 billion in healthcare costs.

Through the implementation of HIV/AIDS programs, in Botswana infant mortality rates have dropped and life expectancy has increased for the first time in many years.
The AIDS response directly benefits the treatment and prevention of other diseases.

The AIDS response
directly benefits the treatment and prevention of other
diseases

ART was associated with a 75 percent decline in the incidence of malaria in a study conducted among HIV-positive patients in Uganda.

Distribution of insecticide-treated nets has been incorporated into comprehensive care strategies for HIV-positive people in many malaria-endemic areas. A qualitative study conducted in HIV-affected households in Rakai, Uganda, reports excellent retention and appropriate use of nets distributed as a part of a PEPFAR-supported community-based outpatient HIV care program.

HIVprogramimplementershavebeguntointegrateTBdiagnosisinto HIV treatment and
care. In one Rwanda program, for example, HIV-positive patients are
now routinely screened for TB. In Uganda, integrated HIV
and TB care at nearly 90 clinics helped achieve a doubling of the
TB assessment rate for ART patientsover two years.

In a study of a South African community with high prevalence of HIV and an established TB
program, there was a significan correlation between the
rollout of ART and a decline (more than 75 percent) in annual TB
notifications among people receiving ART.

The AIDS response is
strengthening health services and primary care
in many settings:

The Global Fund is also a
major contributor to health system strengthening. Approximately 35% of Global Fund
resources are used to that end,
providing invaluable support for human resources, training, and
infrastructure and equipment. In addition to providing
many health systems benefits, scale-upof AIDS services has also
revealed fragilities in health systems that existed before the
AIDS epidemic.33 In some cases, expanded financing for HIV/AIDS
services has placed additional burdens on healthcare workers and
health systems struggling to deliver HIV-related and other
services.

Still, AIDS programming
offers a blueprint for advancingprimary care in
resource-limited countries. A
chronic diseasecharacterized by periods
of illness and periods of health, HIV/AIDS impacts patients and
their families throughout their lives.
The response to AIDS has
led to a patient-centered, holistic modelof care, with high levels
of patient engagement and a range ofsupportive services to
promote retention in care and adherenceto medications.

Delivery of HIV/AIDS treatment has also led to the strengthening of systems to ensure continuity of care that can be replicated to help treat other chronic diseases such as diabetes, cardiovascular disease, and mental illness, and to help tackle problems such as malnutrition and gender and social inequality.

AstudyinruralHaitifoundthatdeliveryofintegratedHIV/AIDS treatment and
prevention helped achieve a number of primary health goals,
including expanded vaccination, family planning, TB case
finding and treatment, and health promotion.The study also showed improved staff
morale and enhanced confidence
in public health and medicine.

Sincethestart of PEPFAR, improvements in the safety andadequacy of blood
supplies have been made in 14 countries with high prevalence of
HIV infection.By 2007, national policies on blood supply
safety had been established in12 PEPFAR countries and
were in development in the two remaining countries.

In Zambia, Namibia, Malawi, Uganda and Guyana, PEPFAR-funded programs have used
financial and other incentives such as special
allowances for housing, transportation, hardship, and education
to promote improved distributionof health workers in
rural and remote areas.

AsHIV treatment programs have been implemented, hospital admissions have
declined dramatically and hospital beds have been freed up
in many communities hit hard by the epidemic.44
For example, after ART was introduced in Botswana, the percentage
of hospital beds occupied by people living with
HIV/AIDS fell from 93 percent to 52 percent in one location.

The AIDS response can
help address the global health workforce crisis

The AIDS epidemic has
ravaged the healthcare workforce in thedevelopingworld. Forexample, in LesothoandMalawi,thesingle greatest cause of
health worker attrition is death from HIV/AIDS.ART roll-out has saved the lives of thousands of healthcare workers,
allowing them to continue providing care.

The World Health
Organization estimates that more than four million healthcare
workers are needed to fill the deficit of doctors, nurses, and
other professionals who form the backbone of the healthcare system.
The situation is most dire in sub-Saharan Africa, which has
11% of the world’s population but 24% of the global burden
of disease and only 3% of the world’s health workers.

The AIDS response has had
a mixed impact on the health worker crisis. For
example, global AIDS initiatives have been associated with some
migration of healthcare workers away from the public sector.
But in many instances, HIV programs have helped to strengthen
healthcare workforce retention by providing new training
opportunities, better working conditions, and other support for
many healthcare workers, such as special
allowances for housing, transportation, hardship, and education
to promote improved distributionof health workers in
rural and remote areas.

Infiscalyear2008,PEPFARspentapproximately $310millionto support training
activities; from 2004 to 2008, the program supported an estimated
3.7 million training and retraining encounters for healthcare
workers.

TheAIDSresponsehasinspired“task-shifting”andotherinnovative solutions to
the workforce crisis, freeing up doctors and nurses to attend to
critical patient needs while cultivating a cadre of engaged
community health workers.1One study in Rwanda demonstrated that
task-shifting the administration of ART reduced demands on
doctors’ time by 76% over a two-year period.

PEPFARhashighlightedthedearthofhealthprofessionalsin Africa and mounted a
strong response, from training and task-shifting initiatives
to a new mandate, included in the 2008 reauthorization of
PEPFAR, that calls for the training of 140,000 new healthcare
workers in 15 target countries by 2014.This and other efforts to address the
workforce crisis will only be realized
with adequate funding.

The AIDS response is
strengthening government and program
accountability

PEPFAR, the Global Fund,
and other HIV/AIDS programs are focused on demonstrating
tangible results based on clear objectives and
accountability measures. This outcomes-driven orientation has been key
to the programs’ success and has helped cultivate similar
performance-based models in other health initiatives.
Indeed the Commission on Smart Global Health Policy at the Center for
Strategic and International Studies has recommended that
PEPFAR-created platforms be the basis for extending more effective
measurement frameworks into other priority health areas.49

Fromitsinception,PEPFAR has set specific targets for delivering AIDS treatment,
reducing rates of HIV infection, and meeting the care needs of
millions of adults, orphans, and vulnerable children.
PEPFAR’s ambitious targets have helped drive planners and
providers to focus on results and have led to the development of new
monitoring and evaluation systems.

Performance-basedfinancing, a founding priniciple of the Global Fund, has created
a variety of mechanisms to ensure accountability, including
key performance indicators on all grants.
Grant recipients are held accountable for specific targets throughout the
life of the grant.

Principles for Moving Forward

Identify opportunities
for new areas of investment whilebuilding on achievements
to date, including HIV/AIDS programs.

The intensive response to
HIV/AIDS through PEPFAR has demonstrated the profound
impact that can be achieved when programs have sufficient
resources and are focused on achieving specific outcomes.The most deadly diseases, such as AIDS, malaria, and TB, will
continue to need dedicated programming even as more funds are
invested in general health systems and other health needs.Disease-specific programs, including
those for HIV/AIDS, will
continue to play a critical role in strengthening overall health systems
and advancing the response to other diseases.

While increasing efforts
to strengthen overall healthcare systems, ensure that
these systems meet the health needs of vulnerable
populations.

Women and girls, gay men
and other men who have sex with men, transgender people,
injection drug users, migrant workers, sex workers, and other
socially marginalized groups are often at elevated risk for HIV and
other health concerns.These
groups are also often
marginalized in their societies, have limited or no access to health
services, and are in some cases not even counted in health statistics.Strengthened health systems can only be effective at addressing a
community’s health needs if they are able to serve those who are most vulnerable.

Recommendations:

Use PEPFAR programming as
a foundation for broader health service
scale up

PEPFAR is evolving from
an emergency relief effort to a comprehensive system for
implementing health interventions in partnership with
countries.It has worked with
countries to develop five-year
strategies, partner implementation plans, and effective approaches
to fund management, metrics, and evaluation. These core
processes, already well established in many countries, can be
used as a foundation for addressing a range of health needs.

Forexample:

ExpandPEPFAR’snewhealth systemstrengtheningframework to address the
other priorities in the President’s Global Health Initiative,
including child and maternal health.

ExpandthePEPFARNewPartnersInitiative
that seeks to enhance the capacity
of NGO, faith-based, and other community efforts to
improve civil society engagement in addressing health needs.

Create incentivesfordifferenthealthservicedeliverynetworks, including
PEPFAR, TB control programs, and Neglected Tropical
Disease service sites to work collaboratively to
maximize cost-effective, high-quality delivery of multiple
health services.

Ensurevulnerablepopulationsathighestrisk(includingMSM, sex workers, and
injection drug users) receive services that meet their
needs as PEPFAR moves to build country capacity.

Ensurethat healthcare professionals trained under PEPFAR also receive clinical
training and mentorship on other relevant infectious
diseases and primary healthcare delivery, including training that
addresses stigma, discrimination, and mistreatment of
marginalized and vulnerable populations.

Strengthen and expand laboratory capacity in countries to respond to diagnostic and
clinical monitoring needs in TB, malaria, maternal and
child health, and family planning.

Ensure the provision of healthcare for women living with or at risk for HIV
infection by integrating family planning services with HIV care
delivery and scaling up the provision of HIV counseling and
testing at family planning sites.

Prioritize the development of integrated systems of screening and care for
HIV and TB to reduce morbidity and mortality in co-infected
persons.

Bring HIV/AIDS and other
global health services to scale

Fund PEPFAR at the levels authorized by Congress through the Lantos-Hyde U.S. Global Leadership AgainstHIV/AIDS, Tuberculosis and Malaria
Reauthorization Act of 2008.

Provide significantly increased resources through the Global Fund and other programs
to ensure the Administration’s Global Health Initiative
broadens the U.S. approach to global health while
maintaining the commitment to scale up the response to HIV/AIDS,
TB, and malaria.

Launch a coordinated operations research agenda across federal agencies to identify the best models for integrating HIV/AIDS programs and other health services.

Coordinate efforts across federal agencies to ensure research findings relevant to the Global Health Initiative are implemented in developing country settings as quickly as possible.

Support the development of local generic ARV productioncapacity in Africa and
craft strategies to drive down the cost of second- and third-line
ARVs.

As the Obama
administration and Congress develop and implement a new Global
Health Initiative, it will be essential to determine the most
strategic approaches and best opportunities for
achieving broad global health goals across a range of diseases and conditions.Evidence to date
indicates that resources committed
to addressing HIV/AIDS can in many cases be leveraged to
strengthen comprehensive healthcare in low- and middle-income
countries.

This article is part of a
special series this week focusing on HIV and AIDS in the United
States. RH Reality Check is partnering with CHAMP, the AIDS Foundation of Chicago, the HIV Prevention
Justice Alliance, and other organizations to highlight issues on domestic HIV and AIDS policy during this week of the National HIV Prevention Conference
in Atlanta, Georgia. See the first piece in this series by Julie Davids and David Munar, The AIDS Crisis in the United States: Wlll the Obama Administration Meet the Challenge?

ATLANTA – Speaking at the
Obama Administration’s first national HIV summit this week, top public health
leaders and community activists agree that a paradigm shift in HIV prevention
approaches is needed to make progress reducing HIV transmission in the
U.S.

According to advocates and other experts,
the U.S. Centers for Disease Control and Prevention (CDC) must work
with partners to develop and implement a strategic scale-up of comprehensive,
combination HIV prevention strategies in order to achieve population-level
decreases in HIV transmission. The aims of a new approach must
focus on averting as many HIV infections as possible. And it must expand
successful interventions, invest in research and evaluation, and address
social drivers such as lack of housing, mass imprisonment, poverty and
marginalization.

There were tantalizing hints at this
week’s conference that CDC may be ready to seek significant changes
in federal prevention policy and programs, a shift that would require
strong leadership to inspire political buy-in and increased resources.
Meanwhile, the new leadership at CDC faces steep challenges contending
with an unprecedented economic crisis and competing national priorities
that could jeopardize progress to slow the spread of HIV in the U.S.

In a seven-page booklet, distributed
to all delegates attending the 2009 National HIV Prevention Conference,
CDC asserts that "the science is clear: HIV prevention can and does
save lives." The document, entitled HIV Prevention in the
United States: At a Critical Crossroads, makes the case for HIV
prevention and articulates CDC’s vision for leading the fight.

The arguments in the report are not
entirely new. As in past reports, CDC describes the dire nature
of the epidemic in the United States and asserts CDC’s vigilance tackling
HIV incidence.

However, some participants at the conference
noted new, refreshing areas of emphasis. CDC’s report, which is going
through the government process for online publication in the next few
weeks, describes the hundreds of thousands of infections – and millions
of health expenditures-averted to date. The report describes
the diverse and complex distribution of the epidemic and the many critical
issues a more robust approach will need to include.

"People don’t know what prevention
is, what they’re getting for their dollar, and why we need to do more,"
explained Terry Butler, a communications specialist with the CDC.
"While we know the value of prevention, there’s a lot of misperception
that prevention is not making a difference – the value of prevention
in terms of lives and dollars saved."

Meanwhile, struggling state economies
have triggered deep budget cuts for public health and HIV prevention
programs across the country. Several speakers at this four-day
conference – presenting innovative HIV prevention activities – acknowledged
fear their programs and jobs will not be sustained in the weeks and
months ahead.

In his opening remarks, the new Division
of HIV/AIDS Prevention (DHAP) Director Dr. Jonathan Mermin didn’t
shrink from describing the challenges posed by the nation’s economic
recession. He described data compiled by the National Alliance
of State and Territorial AIDS Directors (NASTAD) showing $84 million
in HIV-related funding cuts among states surveyed.
A total off 55% of health departments reported funding reductions for
HIV prevention. Importantly, the survey conducted earlier this
year does not even include the estimated $31 million in cuts resulting
from California’s state budget crisis.

CDC’s new booklet details the widening
funding gap at the federal level. While CDC’s HIV prevention
budget has remained relatively stable since 2002, at $750 million annually,
the purchasing power of the budget has declined by nearly 20 percent
as a result of inflation. Additionally, the report describes the
CDC’s professional assessment, calculated in 2008, that an additional
$877 million (a greater than 100 percent increase) is needed annually
to achieve a 50 percent reduction in yearly HIV infections in the U.S.

Mermin, a long-time AIDS clinician
and CDC staffer who spent the length of the Bush Administration in Uganda
and Kenya, has pledged to launch a new strategic planning process for
CDC’s Division of HIV/AIDS Prevention (DHAP) this fall as a component
of the National HIV/AIDS Strategy. He said it will draw upon the
work of the External Peer Review of DHAP’s programs and structure
initiated this Spring. Individuals involved with the external
review say they already see evidence of their recommendations integrated
into Mermin’s remarks defending the cost-benefits of HIV preventions
and justification for a larger investment in HIV prevention.

For example, Dr. Mermin expressed in
his welcoming remarks the need to look at the "social context, including
where people living, poverty, homophobia, race/ethnic bias, gender inequality,
housing status, and HIV stigma," all factors believed to contribute
to elevated risk for HIV acquisition. He also called for a deeper
investment in combination HIV prevention strategies to bridge different
approaches "in multiple disciplines, including biomedical, behavioral,
and community and structural interventions."

The HIV Prevention Justice Alliance
(HIV PJA) secured a meeting with Dr. Mermin on the
closing day of the conference to discuss ways to collaborate with CDC
on efforts to mitigate HIV-related social determinants. Among
the HIV PJA’s demands is CDC’s commitment to develop a framework
that begins to shift the focus of federal HIV prevention from predominantly
individual, behavior-change models to interventions addressing the social
and structural components fueling HIV transmission for entire groups
of people.

But beyond the mere complexity of such
an ambitious undertaking, HIV PJA fears current economic conditions
will undermine even core public health functions from being delivered,
much less new forward-looking plans on root drivers of risk and HIV
acquisition.

Graphically Simplifying a Complex
Epidemic

HIV Prevention in the United States
includesjust two graphs, but they both speak volumes about how
CDC may hope to inspire an increased investment and focus on HIV prevention.
One charts the growing numbers of people living with HIV during a period
of relatively stable HIV incidence (albeit at a rate that we learned
a year ago is much higher than previously thought).

According to Rich Wolitski, Deputy
Director of DHAP, the chart "encapsulates a lot of challenges
and tough decisions facing us," as it indicates that more HIV-positive
people are in need of prevention resources even as the need for primary
HIV prevention for those who are negative remains.

The second breaks down the 2006 incidence
estimate by race/ethnicity, risk group and gender for the most affected
subpopulations, and thus has distinct, descending bars for white men
who have sex with men (MSM), Black MSM, Black heterosexual women, and
so on. As explained by CDC spokesperson Terry Butler, this breakdown
is part of an effort to "better communicate where we are in the epidemic.
The data’s been out there but it’s clearer this way."

After years of euphemistic coding and
strategic de-linking of information on different populations (for example,
much talk of "African American and gay men" but little of "African
American gay men"), these analyses are helpful tools even in clarifying
the realities of the epidemic for conference attendees in the thick
of prevention work. Throughout the conference, CDC has also been gathering
feedback on a possible online tool that will also help a broad range
of people visualize the incidence data broken down to this level of
detail.

The Need for a Big, Good
Idea

On Monday, HHS Secretary Kathleen Sebelius
spoke boldly about the need for an emergency response to the epidemic:

"In 2005, the CDC reported that
in five major cities, almost half of all African-American gay men were
HIV-positive… Think about that. Imagine if it were half the straight
white women in Atlanta. Wouldn’t we be calling this a national emergency?
Shouldn’t we be? That’s how we at HHS are treating it. So we’re
experimenting with innovative new ways to reach these groups – from
a new online banner campaign that targets gay African-American men to
partnering with groups like the Black Women’s HIV/AIDS network."

While greeted by loud applause for
her recognition of the racial and social injustices, the Secretary’s
examples of innovation under-emphasize the many activities at the federal,
state, and local levels needed to heighten the response to HIV/AIDS
among gay men of color. Thankfully, in dozens of presentations
and a CDC listening session on responding to HIV among Men who Have
Sex with Men, participants described the need for programs and services
designed to address the diversity of gay men at risk for HIV.
A speaker from Massachusetts, for example, described the disproportionate
number of HIV-positive gay men who have spent time incarcerated.

The discrepancy between the progressive
analysis and rather standard actions (online banner ads? Partnering
with community networks?") is reflective of some of the post-Bush
CDC initiatives in which long-awaited core activities are perhaps over-lauded
for lack of more radical approaches.

For example, conference participants
spoke of CDC’s new "Act against AIDS" advertising initiative as a decent start
to spark a national dialogue about HIV/AIDS but cautioned, however,
that the campaign cannot be viewed as taking the place of expanded HIV
prevention services needed by people at risk and living with HIV or
strategic structural interventions.

Treatment and prevention integration
dominated many of the discussions this week with advocates and federal
officials anticipating clinical trials will likely show that pre-exposure
prophylaxis with HIV medications can effectively, though not completely,
prevent HIV acquisition. However, the health education, medical and
social systems implementation and financial challenges that would come
with such a breakthrough would be formidable, and comprised the subject
of a day-long meeting here on Sunday.

The concept of reduced "community
viral load" as population-based HIV prevention (where greater numbers
of HIV-positive people on treatment achieve undetectable viral load
and are rendered significantly less infectious) is another bold idea
gaining prominence. Implementing greater treatment and prevention
integration on a large scale, and in the face of significant budget
reductions, remains a daunting task and will likely require greater
coordination and collaboration between different government departments
and agencies to, among other things, pool resources.

Tough Choices, But New Opportunities?

The new booklet speaks quite plainly
about the need to prioritize prevention work.

Advocates and Congress alike have criticized
CDC officials for a lack of transparency and a reluctance or inability
to provide clear and timely information about how they set priorities
and spend the agency’s funding.

In one of the final conference sessions,
CDC unveiled a new resource allocations model that is being designed
and tested to better determine program priorities. And the booklet makes
it quite plain that "difficult choices" will have to be made, with
"resources… directed to the populations at the highest risk and
to the strategies that are the most cost-effective in reducing HIV transmission."

As explained by Wolitski, the "crossroads"
referred to in the publication’s title ("At a Critical Crossroads")
alludes to the imperative to make difficult, strategic choices in an
era of increased need and diminished resources.

"We’re at a point of having to
ask these questions. We are doing the external review, a strategic plan,
there’s the national HIV/AIDS strategy and health care reform. A lot
of things today are changing. We have to look at the data and variables,
and assess how what CDC does fits in a broader framework of providers,
private insurance, medical care systems and so on. That’s why the
tough choices are now so salient."

New CDC Director Thomas Frieden, former
commissioner of New York City’s health department, is no stranger
to embracing controversy in the face of what he feels is in the best
interests of public health. Advocates note his past efforts supporting
access to condoms, syringe exchange and – incurring the wrath of some
advocates — pushing for legislative changes to allow for HIV testing
without written informed consent or counseling. But his presence at
the podium was limited to an introduction of HHS Secretary Sebelius,
far from showing his hand or sketching out a vision of change.

Last year, the National Center for
HIV/AIDS, Viral Hepatitis, STD, and TB Prevention held a consultation
to consider the adoption of a social-determinants framework. While its
Director, Dr. Kevin Fenton, has pushed for such a framework, it remains
unclear whether new leadership at CDC will embrace a model that posits
factors such as poverty, homophobia and mass imprisonment of African
Americans and Latinos as likely drivers of the epidemic – or if they
would actually move from a modeling to significant action.

It’s widely speculated that any re-thinking
of CDC policy must reduce dependence on pre-packaged "boxed interventions,"
which have failed to meet the nation’s HIV prevention needs but been
the mainstay of funded programs. Thus, some speculate that community-rooted
prevention workers could be shunted aside rather than retrained under
a new vision of comprehensive HIV prevention. Advocates have begun to
speak out to demand that, if changes do come, those leading HIV prevention
efforts in our communities will be given the opportunity for training
and support to integrate and bolster new efforts, but this was not addressed
in Atlanta this week.

The National AIDS Strategy to the
Rescue?

Throughout the conference, there was
much talk of the potential capacity of the National HIV/AIDS Strategy
(NHAS) being coordinated by the White House Office of National AIDS
Policy as a tool for turning tough choices into big, new ideas for prevention
progress and inspiring re-investment in reducing incidence.

The placement of noted CDC researcher
Greg Millett as a Senior Policy Advisory for the NHAS has been lauded
as a step in the right direction. ONAP held a well-attended input session
at the conference to launch development of the NHAS, with dozens of
people testifying on their priorities for the plan, and Mr. Crowley
spoke on a plenary session devoted to inter-governmental collaboration.

The NHAS is, in and of itself, a big,
new idea in the domestic epidemic. The challenges of a truly implementable
strategy are formidable, but fully consistent with the need for CDC
to devise a more strategic and rigorous approach. Only through
bold, new leadership to chart a new, strategic path is there any chance
to confront stubbornly persistent HIV incidence in our country.

]]>http://rhrealitycheck.org/article/2009/08/27/federal-hiv-prevention-officials-speak-freely-science-marginalized-groups-and-funding/feed/0AIDS 50 Times Higher In Gay/Bi-Men Than Other Groupshttp://rhrealitycheck.org/article/2009/08/25/aids-50-times-higher-in-gaybimen-than-other-groups/?utm_source=rss&utm_medium=rss&utm_campaign=aids-50-times-higher-in-gaybimen-than-other-groups
http://rhrealitycheck.org/article/2009/08/25/aids-50-times-higher-in-gaybimen-than-other-groups/#commentsTue, 25 Aug 2009 07:00:00 +0000Recent data indicate that HIV and AIDS affect gay and bisexual men at rates grossly disproportional to other groups. Why did it take CDC so long to ask these questions and what will we do to answer them?

This article is part of a
special series this week focusing on HIV and AIDS in the United
States. RH Reality Check is partnering with CHAMP, the AIDS Foundation of Chicago, the HIV Prevention
Justice Alliance, and other organizations to highlight issues on domestic HIV and AIDS policy while
several thousand people attend the National HIV Prevention Conference
in Atlanta, Georgia. See the first piece in this series by Julie Davids and David Munar, The AIDS Crisis in the United States: Wlll the Obama Administration Meet the Challenge?

CDC official Dr. Amy Lansky announced today at a plenary session of the National HIV Prevention Conference the CDC’s finding that, in the United States, gay men and other men who have sex with men (MSM) have AIDS at a rate more than 50 times (that’s right, FIFTY TIMES) greater than women and non-gay/bi men. This confirms in emphatic terms that of all the disparities and disproportionate impacts in the HIV/AIDS epidemic in the United States, the greatest one is the extraordinarily disproportionate impact on gay and bisexual men — of all races and ethnicities– though the most disproportionate impact is on African American gay, bi and other MSM.

As incidence estimates released by CDC last year revealed, MSM constitute more than half of all new cases of HIV and are the group in which the number of new cases each continues to slowly increase. What’s new today is that the CDC has calculated *rates* of HIV/AIDS prevalence among MSM, not just raw numbers. Lansky says the CDC estimates that there were 692.2 new HIV cases in 2007 per 100,000 MSM. Having a rate as well as the raw numbers allows comparisons for the first time to other population groups at risk, such as women and heterosexual men.

In turn, to calculate a rate, one must be able to know or estimate the size of the underlying population. It’s fairly easy to know how many women or African Americans or Latinas/os there are in the country or a state or a community. It’s not so easy to know how many gay men there are, especially since many gay and bi men have reasons not to disclose their sexual orientation and since the government has not been especially interested in accurately counting us. The CDC took a range of estimates from several nationally representative surveys and studies and decided to use the figure of 4.0%, representing the median estimate of the proportion of adolescent and adult men who acknowledge having had sex with another man in the past five years.

Why has it taken so long to make this estimate, which in turn allows population comparisons and impact assessments? Maybe part of it is due to natural scientific reluctance to make guesses about things that cannot be accurately measured. But that doesn’t really make sense, because policymakers push scientists all the time to make estimates about hard-to-measure phenomena affecting public policy. Seems clear to me that this was at least an indirect effect of the pervasive homophobia still affecting much of government, public policy, media and societal norms in this country.

At the same time we applaud this newly honest statement and comparison, and what it means about the continuing devastating impact on MSM communities and populations, most especially on MSM of color, it is equally important to reaffirm the devastating and disproportionate impact that HIV has as well on other populations and communities, particularly women of color in the South and elsewhere and on transgender women in urban areas throughout the country.

We must fight for funding and adequate social investment to end HIV/AIDS wherever it continues to persist and thrive, which is almost always where concentrated social injustice also thrives. We will not decisively end AIDS anywhere unless we end it everywhere.

]]>http://rhrealitycheck.org/article/2009/08/25/aids-50-times-higher-in-gaybimen-than-other-groups/feed/0Guest Blogger: UN Meeting on AIDS Must Include “All”http://rhrealitycheck.org/article/2008/06/10/guest-blogger-un-meeting-aids-must-include-all/?utm_source=rss&utm_medium=rss&utm_campaign=guest-blogger-un-meeting-aids-must-include-all
http://rhrealitycheck.org/article/2008/06/10/guest-blogger-un-meeting-aids-must-include-all/#commentsTue, 10 Jun 2008 12:00:00 +0000Live-blogging from the UN meeting on AIDS: HIV stigma fuels the invisibility of many populations afflicted by this disease - when we say we want to reach "all" groups of people, we should mean it.

]]>
This week, the general assembly of the U.N., along with educators, advocates, activists, researcher, and healthcare professional from civil society around the world are gathering in New York for the U.N. High Level Meeting on AIDS. This meeting was called last December by a resolution adopted by the General Assembly to assess the progress being made in implementing the 2001 Declaration of Commitment on HIV/AIDS and the 2006 Political Declaration on HIV/AIDS.

On the first day, I attended a session entitled "Full Enjoyment of Human Rights by All: Vulnerable Groups Social Exclusion and Progress towards Universal Access." This was co-organized by amFAR, the Global Forum on MSM and HIV, UNDP, and the UNAIDS Secretariat.

The title made me think about the word "all". Obviously, we want human rights for all, for everyone – and it seems like we use this word as a euphemism at times to express that inclusivity. Like those progressive religious congregations that use it to subtly let LGBT individuals know they are welcome. While it’s a far cry from the loud rallying of the early LGBT movement’s "We’re here. We’re queer. Get used to it," it can be necessary to open doors, start conversations, and reach those individuals such as those who identify as MSM (men who have sex with men) who may not identify as LGBT.

The problem is that in many countries around the world, these groups get swept up into the all, becoming invisible in and of themselves, and we end up not knowing nearly enough about them.

And so, visibility of men who have sex with men and other LGBT individuals emerged as the central and reverberating theme of the session. Despite the astounding prevalence rates of HIV among MSM, gay men, and transgender individuals as compared to general adult populations around the world, they remain glaringly invisible. Invisible in the epidemiological data, in government gathered national HIV/AIDS surveillance data, in the country progress reports to the U.N. high level meeting, and in so many countries, cultures, towns, and families.

The end result is that we don’t know enough about how many individuals need prevention, care, and treatment services. We don’t know how many have been reached by these services. We don’t know what types of programs and services work best.

We just don’t know enough.

Stigma fuels this invisibility, allowing these individuals to be easily dismissed or forgotten. At the same time, the invisibility fuels the stigma because solid policies and programs must be based on evidence. In the absence of evidence the response can never be as robust or effective as it must be, and policies and programs are more vulnerable to influence from ideology and hypermoralism.

Surveillance data must be disaggregated, epidemiological studies of MSM, gay and transgender populations must be conducted with the same rigor as any other populations, and governments must include surveillance criteria regarding percentages of MSM, gay, and transgender populations reached.

When we say all, we should mean it, and we should have the data to back it up.

]]>http://rhrealitycheck.org/article/2008/06/10/guest-blogger-un-meeting-aids-must-include-all/feed/0What About the Boys? Young Men at Riskhttp://rhrealitycheck.org/article/2008/03/14/what-about-the-boys-young-men-at-risk/?utm_source=rss&utm_medium=rss&utm_campaign=what-about-the-boys-young-men-at-risk
http://rhrealitycheck.org/article/2008/03/14/what-about-the-boys-young-men-at-risk/#commentsFri, 14 Mar 2008 08:51:20 +0000Yesterday the CDC finally released data it had long held internally that demonstrates an alarming increase in the number of HIV/AIDS cases among young African-American men who have sex with men (MSM).

]]>On Wednesday the CDC finally released data it had long held internally that demonstrates an alarming increase in the number of HIV/AIDS cases among young African-American men who have sex with men (MSM).

No one seems to know why it took more than a year for the data analysis to become public — the data itself is now three years old — or why it was released by email as a "slide set" with little fanfare or press attention.

Perhaps the reason the Administration delayed the release of the data is because the majority of AIDS cases among men can be attributed to male-to-male contact (59 percent). In fact, from 2001 to 2005, the number of HIV/AIDS cases increased among adult and adolescent men who have sex with men (MSM) in all age groups. The largest proportional increase occurred among MSM ages 13-24, with young African American/black MSM in this age category suffering the largest increase — up almost 80 percent from 2001 to 2005!

Is homophobia fueling an irrational and dangerous response to a public health epidemic that has plagued us for more than 25 years? I wouldn't be surprised. After all this is the administration that has poured more than $1 billion into abstinence-only-until-marriage programs-programs that at their best ignore the existence of gay youth and at their worst demonize homosexuality.

Isn't it time we demanded a rational and more urgent public health response to an epidemic that has killed so many? Young men who have sex with men are becoming infected with HIV at an alarming rate. They need information. They need services. They have the right to respect and acceptance.

Until honest education and access to services become common, the lion's share of the blame for the increase in HIV/AIDS among young MSM will continue to rest squarely with the President who has championed failed abstinence-only programs, the legislators that have funded them, and all those who perpetuate or tolerate homophobia.